J Clin Exp Dent. 2018;10(6):e561-6.

Retrospective study of gingival lesions

Journal section: Oral Medicine and Pathology doi:10.4317/jced.54766

Publication Types: Research http://dx.doi.org/10.4317/jced.54766

Histopathologic analysis of gingival lesions: A 20-year

retrospective study at one academic dental center

Jazia A. Alblowi 1, Nada O. Binmadi 2

1
BDS, DSc, DABP, Assistant Professor, Periodontology Department, King Abdulaziz University, Faculty of Dentistry, Jeddah,
Saudi Arabia
2
BDS, MBA, PhD, Assistant Professor, Oral Diagnostic Sciences Department, King Abdulaziz University, Faculty of Dentistry,
Jeddah, Saudi Arabia

Correspondence:
Oral Diagnostic Sciences Department
King Abdulaziz University
Faculty of Dentistry, Jeddah, Saudi Arabia
nmadi@kau.edu.sa
Alblowi JA, Binmadi NO. Histopathologic analysis of gingival lesions:
A 20-year retrospective study at one academic dental center. J Clin Exp
Dent. 2018;10(6):e561-6.
Received: 25/02/2018
Accepted: 26/04/2018
http://www.medicinaoral.com/odo/volumenes/v10i6/jcedv10i6p561.pdf

Article Number: 54766 http://www.medicinaoral.com/odo/indice.htm

© Medicina Oral S. L. C.I.F. B 96689336 - eISSN: 1989-5488
eMail: jced@jced.es
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Abstract
Background: The gingiva is part of the periodontium supporting structures surrounding the teeth and commonly
involved in gingival and periodontal conditions. Assessing the distribution of gingival lesions is important for eva-
luating the prevalence of periodontal disease in the population to optimize the oral health care services. The purpose
of this study is to report the frequency and distribution of gingival lesions biopsied from 1996–2016.
Material and Methods: This cross-sectional retrospective study retrieved data from all gingival lesions biopsied
from 1996–2016 and sent to the King Abdulaziz University Dental Hospital oral pathology laboratory. Histologic
sections were reviewed in a blinded manner by a certified oral pathologist to confirm the initial histologic diagnosis.
Results: Of the 1,248 oral-maxillofacial lesions, 119 (9.5%) gingival lesions were diagnosed. The mean age was
41.58 years. Gingival lesions were more prevalent in female patients than male patients (53.8%). The most com-
mon diagnoses were reactive lesions (41.2%). Pyogenic granuloma was the predominant lesion in the category
(n=26, 21.8%), and followed by inflammatory conditions (24.4%), benign neoplasm (9.2%), malignant neoplasm
(7.6%), epithelial lesions (7.6%), miscellaneous (5%), and immune-mediated diseases (5%). Squamous cell carci-
noma was the only malignant neoplasm reported (7.6%; mean age, 57.44 years) and more common in male than
female patients (2:1). Most biopsies were sent from oral and maxillofacial surgeons (55.6%) followed by general
dentists (22.2%) and periodontists (12.8%).
Conclusions: Pyogenic granuloma was the most common gingival lesion. Squamous cell carcinoma was the only
malignant lesion in which histologic examination was the definitive diagnostic measure. This study provides infor-
mation about the frequencies and distributions of gingival lesions over 20 years.

Key words: Gingival biopsies, retrospective, reactive lesions, oral pathology.

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J Clin Exp Dent. 2018;10(6):e561-6.
Introduction
Gingiva is a part of the periodontium-supporting struc-
tures surrounding the teeth and commonly involved in
gingival and periodontal diseases. It can be subjected
to trauma or irritation. It is a common site for various
pathologic diseases (1,2). Despite the fact that gingivi-
tis is the most common disease involving the gingiva,
many other uncommon local or systemic pathologic
conditions also may involve the gingiva, which necessi-
tates that periodontists and pathologists work together to
reach the appropriate diagnosis to ensure timely diagno-
sis and management (3).
Although diagnoses of gingival diseases and conditions
depend on the clinical features, histologic examination
might be needed to confirm the diagnosis as well as to
rule out a neoplastic nature of the process. Only a few
epidemiologic studies were reported in the literature re-
garding gingival lesions (2,4-8).
In Saudi societies, little is known about the frequencies
of different oral lesions as confirmed by histologic diag-
nosis. Most of these studies investigated oral lesions in
general and indicated the prevalence of malignancies in
different areas of the oral cavity (6,7). The prevalence of
lesions might vary in different countries and geographic
locations and the histologically confirmed diagnoses of
gingival lesions are not well reported in Saudi Arabia.
The purpose of this study is to evaluate the frequencies
and distributions of gingival lesions biopsied at King
Abdulaziz University Dental Hospital during the last 20
years from 1996-2016 diagnosed by clinical and histo-
logic features.
Material and Methods
This retrospective cross-sectional study was approved
by the Research Ethics Committee, Faculty of Dentis-
try, King Abdulaziz University (protocol number: 088-
16). All gingival biopsies (n=119) sent to the Oral and
Maxillofacial Pathology (OMFP) laboratory at King
Abdulaziz University, Jeddah, Saudi Arabia from di-
fferent departments in the Faculty of Dentistry at King
Abdulaziz University Dental Hospital during the period
from 1996–2016 were evaluated and the corresponding
medical records were reviewed. Cases with inadequate
histories or reports (n=7) were not included in the sam-
ple. The archived demographic data concerning age and
sex were retrieved. The referring dentists and specialists
were also recorded. All patients’ identifiers were remo-
ved and the samples were given unique identifiers. The
location and type of the gingival lesions were obtained
from the register of the pathology laboratory and clini-
cal information concerning the lesion was retrieved from
the corresponding biopsy request form. The archived
5-µm-thick paraffin sections, which were stained pre-
viously with hematoxylin and eosin, were reviewed by a
certified oral pathologist to confirm the initial histologic
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Retrospective study of gingival lesions
diagnosis in a blinded manner. The lesions were clas-
sified into groups as follows: reactive/adaptive lesions,
inflammatory lesions, benign neoplasms, malignant neo-
plasms, epithelial lesions, immune-mediated diseases
(IMD), and miscellaneous.
Statistical analysis was performed using the Statisti-
cal Package for the Social Sciences (SPSS) version 22
(IBM Corp., Armonk, NY, USA). Categorical variables
are presented as numbers, nominal variables as percen-
tages, and continuous variables as means and standard
deviations.
Results
Over the 20-year duration (1996-2016), 119 gingival
tissue samples were diagnosed out of the total of 1,248
oral-maxillofacial lesions, so the incidence of gingival
lesions was 9.5%. Of the 119 patients, 64 of were female
(53.8%) and 55 patients were male (46.2%) with a mean
age of 41.58 years (range, 6-84 years). The youngest, a
6-year-old male child, had a myofibroma, and the oldest,
an 84-year-old man, had mild dysplasia.
The most frequent histopathologic category along with
age and sex distributions is summarized in Table 1. The
most common diagnoses were reactive lesions, which
accounted for 41.2%, followed by inflammatory lesions
(24.4%), benign neoplasms (8.4%), malignant neoplas-
ms (7.6%), epithelial lesions (7.6%), miscellaneous
(5.9%), and IMD (5%).
Table 2 shows the frequency of each histopathologic
diagnosis along with age and sex distributions. The most
common reactive/adaptive lesion in the gingival tissue
was pyogenic granuloma (n=26, 21.8%) (Fig. 1a), which
was more common in male patients (n=15) with a mean
age of 32.12±15.21 years. The most frequent inflam-
matory lesion was chronic gingivitis (n=22, 18.48%)
(Fig. 1b) and was more common in female patients
(n=14) with a mean age of 36.62±19.54 years. Fibro-
ma was the predominant benign neoplasm (n=11, 9.2%)
(Fig. 1c) and was equally distributed among male and
female patients with a mean age of 43.30±15.81 years.
Oral squamous cell carcinoma (OSCC) was the only
malignant neoplasm reported in gingival tissue among
our specimens (n=9, 7.6%) (Fig. 1d) with a mean age
of 57.44 years; it showed a male predominance (ma-
le-to-female ratio: 2:1). Hyperkeratosis and acanthosis
(n=7, 5.88%) were the most commonly observed histo-
pathologic findings among epithelial lesions and were
observed more frequently in male patients with a mean
age of 42±20.9 years. Among immune-mediated lesions,
lichen planus (n=4, 3.36%) was the most common with
a 1:1 male-to-female ratio and mean age of 47.5±13.53
years. Miscellaneous cases such as metal pigmentation,
intramucosal nevus, and normal tissue accounted for 5%
of the total number of gingival specimens.
The dental specialty referral pattern for gingival speci-
J Clin Exp Dent. 2018;10(6):e561-6. Retrospective study of gingival lesions

Table 1: Frequencies of different histopathologic categories with age and sex distributions.

Classification Number Percentage Mean age SD M:F

(range) in years
Reactive/adaptive 49 41.2 32.90 (7–80) 16.94 1:0.9
Inflammatory 29 24.4 36.11 (12–72) 17.63 1:2.2
Benign neoplasm 11 9.2 43.3 (25–76) 15.81 1:1
Malignant neoplasm 9 7.6 57.44 (34–80) 15.61 2:1
Epithelial 9 7.6 48.25 (27–84) 23 3:1
Miscellaneous 6 5.0 29.86 (6–51) 14.88 1:1.3
Immune-mediated disease 6 5.0 43.17 (21–66) 15.09 1:2
Total 119 100.0

Table 2: Age and sex distributions for each histopathologic diagnosis.

Diagnosis Number Male Female M:F Mean age SD
(years)
Reactive/adaptive
Pyogenic granuloma 26 15 11 1:0.73 32.1 15.21
Fibrous epulis 17 6 11 1:1.83 36.3 20.79
Peripheral ossifying fibroma 3 2 1 2:1 30 22.11
Localized juvenile spongiotic 1 1 0 0 22 0
gingival hyperplasia
Gingival fibromatosis 1 0 1 0 28 0
Peripheral giant cell granuloma 1 0 1 0 0 0
Inflammatory
Chronic inflammation (chronic 22 8 14 1:1.75 36.6 19.54
gingivitis)
Plasma cell gingivitis 5 0 5 0 33.5 9.26
Foreign body reaction 2 1 1 1:1 36 12.73
Benign neoplasm
Fibroma 10 5 5 1:1 43.3 15.81
Myofibroma 1 1 0 0 6 0.00
Malignant neoplasm
Squamous cell carcinoma 9 6 3 1:0.5 57.4 15.61
Epithelial
Hyperkeratosis and acanthosis* 7 5 1 5:1 42 20.90
Mild epithelial dysplasia 2 1 1 1:1 67 24.04
Miscellaneous
6 2 4 1:2 33.8 11.53
Immune-Mediated
Lichen planus 4 2 2 1:1 47.5 13.53
Mucous membrane pemphigoid 2 0 2 0 34.5 19.09
*the sex was undetermined in some cases.

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J Clin Exp Dent. 2018;10(6):e561-6. Retrospective study of gingival lesions

Fig. 1: Histopathologic images of (a) a pyogenic granuloma showing ulceration of the oral epithelium with
proliferation of new blood vessels and chronic inflammation are shown -H&E ×4; (b) gingival tissue shows fo-
cal diffuse infiltration of chronic inflammatory cells (chronic gingivitis) -H&E ×4; (c) a fibroma with thickened
collagen bundles around the vessels in the lamina propria- H&E ×10; and (d) squamous cell carcinoma shows
malignant cellular and architectural changes such as hyperchromatism, polymorphism, and keratin pearls -
H&E ×20.

mens was distributed as follows: oral and maxillofacial
surgeons, 54.6% (n = 65); general dentists, 23.2% (n =
28); periodontists, 12.6% (n = 15); oral medicine prac-
titioners, 8.4% (n = 10); and orthodontists, 0.8% (n = 1)
(Fig. 2).
Discussion
To the best of our knowledge, the present study repre-
sents first attempt to report on the frequency and distri-
bution of the gingival lesions biopsied at King Abdula-
ziz University Dental Hospital during the last 20 years
from 1996–2016 diagnosed on the basis of clinical and
histologic features.
The total number of gingival lesions (n=119) accounted
for 9.5% of all cases analyzed by the laboratory. Most
gingival lesions in this study were from the middle-age
group with a mean age of 41.58 years, which was older
than the ages in studies performed by Kamath et al. and

Fig. 2: Distribution of the specimens’ referral sources by specialty.

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J Clin Exp Dent. 2018;10(6):e561-6.
Shamim et al. (5,8). The gingival lesions were predomi-
nant in female patients (53.8%) compared to male pa-
tients (46.2%); which was consistent with the findings of
other reported retrospective studies (5,8-11). Although
non-neoplastic lesions were prevalent in females, neo-
plastic lesions were more prevalent in males.
The majority of samples were found to be non-neoplas-
tic lesions. The most common gingival lesions were re-
active/adaptive lesions (41.2%) (Table 1) with more pre-
valence in male patients than females and in agreement
with the earlier report by Kamath et al. (5). Pyogenic
granuloma was the most common lesion in this cate-
gory. The results were similar to earlier reports (8-10).
Pyogenic granuloma represented more than one-fifth of
all gingival lesions with a peak incidence of occurrence
at age 32.1 years, which was slightly older than earlier
reports (8). It is more prevalent in males than females
of our study population which is in contrast to earlier
reports which showed female prevalence (8-12). Pyoge-
nic granuloma was clinically characterized as a gingival
lump that bled easily and demonstrated surface ulcera-
tion (12,13).
The second most common gingival lesion was inflam-
matory conditions and chronic inflammation was the
most frequent histologic finding. Gingivitis is a common
form of the inflammatory disease that results as a res-
ponse to plaque accumulation (14). Gingivitis was pre-
valent in female patients with a mean age of 36.6 years,
which was older than the age reported by Ababneh (10).
Fibroma was the most common benign tumour, accoun-
ting for 8.4% (n=10) of the gingival lesions and is in
agreement with earlier reports (5,8). It was distributed
equally among males and females. The peak incidence
of occurrence was at the age of 43.3 years, similar to
the results of the study performed by Shamim et al. (8).
Malignant neoplasms of the gingiva accounted for 7.6%
of the total number of cases, which was higher than re-
ported in the study by Manjunatha et al. (9) but lower
than reported in other epidemiologic data (5,8,10) and is
in accordance with reports by Mario Carbone et al. (11).
OSCC was the only malignant neoplasm reported in gin-
gival biopsy specimens in this study, which was in ac-
cordance with the results of many other studies (5,8,11).
The gingiva is considered one of the most common sites
for OSCC (11). The mean age of occurrence of OSCC
in our study was 57.4 years and was more common in
males, which is an agreement with the results of Kamath
et al. and Ababneh (5,10).
The epithelial lesions represented 7.6% (n=9) of the
biopsied gingival lesions. Mild dysplasia accounted for
22 % (n = 2) of epithelial lesions. The prevalence is hi-
gher than that found by Carbone and coworkers (11).
IMD can present clinically in the gingiva as an ulcer,
vesicles, or erosive lesions and is called desquamative
gingivitis. The most common IMD in gingival was pem-
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Retrospective study of gingival lesions
phigoid, which differed from our findings that showed
oral lichen planus as the most common lesion in this
category and is in agreement with reports by Mario Car-
bone et al. (11).
Almost all users of the gingival biopsy and histopatho-
logy services at the school were dental specialists; only
22.2% were general dentists. Most specimens were sub-
mitted by oral and maxillofacial surgeons followed by
periodontists and oral medicine specialists. This result is
different from that in the study by Wan et al. where oral
medicine specialists submitted the most oral biopsies in
Australia (15). Haberland et al. showed that most oral
pathology referrals were from general dentists followed
by periodontists (16). We think that most of oral lesions
cases were referred to oral surgeons for management ra-
ther than oral medicine specialists because of unrecog-
nition and loss of identity of this specialty in non-acade-
mic sectors in the country.
One of the limitations of this study is the sample size,
which could be explained in part by the fact that this
study was conducted at only one academic centre. Mo-
reover, we were unable to evaluate risk factors such as
socioeconomic status, occupation, and oral habits in this
study, which were usually not mentioned on the requi-
sition forms.
In conclusion, the current data can be useful in updating
information regarding the prevalence and characteristics
of gingival lesions in this region. This is crucial, as it
shows that clinicians in general and periodontists in spe-
cific were most of the gingival lesions referred to, the
types of lesions that they might expect to encounter in
their practices. It also serves as baseline data for future
prevalence studies on gingival lesions in Jeddah. Fur-
ther multicenter studies are encouraged to better repre-
sent the epidemiologic findings of gingival lesions in the
Saudi population.
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Fund
The authors declare that the work was not supported or funded by any
institution or organization.

Conflict of interest
This manuscript has not been published or presented elsewhere in part
or in entirety and is not under consideration by another journal. We
have read and understood your journal’s policies, and we believe that
neither the manuscript nor the study violates any of these. The authors
have no conflicts of interest.

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